Pulmonary Angiopathy in Severe COVID-19: Physiologic, Imaging, and Hematologic Observations

• DOI: 10.1164/rccm.202004-1412oc
• Publication Date: 2020-07-15T14:47:12Z
• Authors: Brijesh V. Patel; Deepa J. Arachchi...; Carole A. Ridge; Paolo Bianchi; James F. Doyle; Benjamin Garfield; Stephane Ledot; Cliff Morgan; Maurizio Passariello; Susanna Price; Suveer Singh; Louit Thakuria; Sarah Trenfield; Richard Trimlett; Christine Weaver; S. John Wort; Tina Xu; Simon P. G. Padley; Anand Devaraj; Sujal R. Desai
• Keywords: Adult; Male; Pulmonary Circulation; Respiratory System; Pneumonia, Viral; 610; mechanical ventilation; Betacoronavirus; thoracic imaging; 616; Humans; Vascular Diseases; Lung; Pandemics; 11 Medical and Health Sciences; Aged; SARS-CoV-2; COVID-19; Original Articles; acute respiratory distress syndrome; Middle Aged; pulmonary perfusion; 3. Good health; novel coronavirus disease 2019; Female; Coronavirus Infections; Tomography, X-Ray Computed

Rationale: Clinical and epidemiologic data in coronavirus disease (COVID-19) have accrued rapidly since the outbreak, but few address the underlying pathophysiology.Objectives: To ascertain the physiologic, hematologic, and imaging basis of lung injury in severe COVID-19 pneumonia.Methods: Clinical, physiologic, and laboratory data were collated. Radiologic (computed tomography (CT) pulmonary angiography [n = 39] and dual-energy CT [DECT, n = 20]) studies were evaluated: observers quantified CT patterns (including the extent of abnormal lung and the presence and extent of dilated peripheral vessels) and perfusion defects on DECT. Coagulation status was assessed using thromboelastography.Measurements and Results: In 39 consecutive patients (male:female, 32:7; mean age, 53 ± 10 yr [range, 29-79 yr]; Black and minority ethnic, n = 25 [64%]), there was a significant vascular perfusion abnormality and increased physiologic dead space (dynamic compliance, 33.7 ± 14.7 ml/cm H2O; Murray lung injury score, 3.14 ± 0.53; mean ventilatory ratios, 2.6 ± 0.8) with evidence of hypercoagulability and fibrinolytic "shutdown". The mean CT extent (±SD) of normally aerated lung, ground-glass opacification, and dense parenchymal opacification were 23.5 ± 16.7%, 36.3 ± 24.7%, and 42.7 ± 27.1%, respectively. Dilated peripheral vessels were present in 21/33 (63.6%) patients with at least two assessable lobes (including 10/21 [47.6%] with no evidence of acute pulmonary emboli). Perfusion defects on DECT (assessable in 18/20 [90%]) were present in all patients (wedge-shaped, n = 3; mottled, n = 9; mixed pattern, n = 6).Conclusions: Physiologic, hematologic, and imaging data show not only the presence of a hypercoagulable phenotype in severe COVID-19 pneumonia but also markedly impaired pulmonary perfusion likely caused by pulmonary angiopathy and thrombosis.